Equity and efficiency in health reform. A European view

Health care reform in both eastern and western Europe is on the agenda, and in both parts of Europe the importance of equity targets has been questioned. In the East, the previously strongly held equity goals were largely a facade, covering all sorts of privilege systems, something which has brought equity as a concept into disrepute. However, present developments mean that it is quite likely to be back on the agenda again soon. In the West, equity has been seen as inevitably linked to non-market systems of health care. In moving towards market solutions equity has come to be seen as conflicting with efficiency goals. This contra-positioning of equity and efficiency does not stand up to critical examination. It is based on confusing strategic goals with the implementation of those goals. Equity could be seen as a strategic goal in its own right. We may ask what are the most efficient ways of financing, managing and delivering medical services to achieve that goal. Clearly this has not been the question on the agenda. Cost containment has been imperative, and the consequences for general health, equity in health or the health and care for those suffering most, has been relegated to second place. The reduction of inequalities in health can be seen as an overall strategy for the improvement of a population's health, and as helpful in the maintaining and improvement of its human capital. If the focus is on reducing inequality in health, however, policies other than those preoccupied with the financing, management and delivery of medical services must be given much more thought and a more strategic role, both in eastern and western Europe. The concept of health reform must embrace a wider range of policies and considerations that that of medical care reform.